Healthcare Provider Details

I. General information

NPI: 1902003254
Provider Name (Legal Business Name): RANDALL K CUNDIFF
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/29/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 N MAIN ST
CIMARRON KS
67835
US

IV. Provider business mailing address

107 N MAIN ST
CIMARRON KS
67835
US

V. Phone/Fax

Practice location:
  • Phone: 620-855-4616
  • Fax: 620-855-4613
Mailing address:
  • Phone: 620-855-4616
  • Fax: 620-855-4613

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateKS

VIII. Authorized Official

Name: MS. JULIE FRANCO
Title or Position: BILLING AGENT
Credential:
Phone: 316-263-0776